When we think about what we want for health care as individuals—the kind of care we want to receive when we are injured, sick, not at our best—it is care that is timely, compassionate, nurturing, and ultimately just makes us feel better. When we are in the health care setting, we want to feel listened to and cared for from the time we make our appointment, check in at the front desk, see our provider, implement our treatment, and receive follow-up.
Our dedicated health care providers work hard every day to deliver the kind of care we all desire. As Chief Executive Officer of Gifford Hospital, Dan Bennett puts it in a recent interview, “When [new providers] come to our organization, I’ll ask them, ‘So why did you choose this line of work?’ And ultimately, it’s because they want to take care of people.” Unfortunately, the way our current fee-for-service system is set up, providers are incentivized to provide billable health services to maximize volume. This volume-focused approach overlooks non-billable activities that improve health, which works against the way providers are trained to deliver care, and neglects the human treatment patients are looking to receive.
OneCare Vermont’s Payment Reform model is carefully designed to improve the quality of care by changing the way we pay for health care. Efficiency is inherently embedded in the way the fixed payments to providers are structured. As the Chief Medical Officer of Gifford Hospital, Dr. Josh White, in Randolph says of OneCare’s payment reform model, “It creates the right frame of mind for how we address people and incentivizes providers to perform the test they need, because that goal is health. And so if you neglect something, and the patient does poorly later on, there’s going to be cost associated with that.”
This is an important point. The idea of a fixed payment for a population of patients can make some wonder if providers will avoid providing necessary care as a means to stay within their fixed budget. In fact, the opposite is true. As Dr. White notes, physicians under fixed payment programs are incentivized to make sure they are ordering the right tests, services, procedures—and also exploring social determinants of health that may need to be addressed like food access, housing, and social connection—as a means to prevent a more significant health issue later on. The concept of “rationing care” is absolutely not incentivized by the OneCare payment reform model because providers are paid based on the quality of care they deliver, and that requires a strong emphasis on prevention. This is referred to as “value-based care,” because it encourages and rewards investments in primary care, health prevention, early identification of disease, and treatment.
Unlike value-based care, volume-based care or the service transaction model (also known as fee-for-service) rewards providers for seeing as many patients and ordering as many tests as possible. By shifting the incentive from volume to value, with an added focus on quality, OneCare Vermont and its network of providers have the opportunity to lower costs while delivering better health care. As Bennett remarks regarding the shift to value-based care through payment reform, “If you are a CEO or a CFO or leader of a hospital, this is the kind of system that is going to allow you to take care of your community. The OneCare team helps us understand the funds that are available, so that we can impact health and eventually impact the total cost of care for our community—which benefits everybody.”
When providers are reimbursed for value instead of volume, over time, they can change the way they deliver health care by investing in traditionally non-billable health care activities that are designed to lead to better health outcomes. This is another important point—that providers are incentivized to add value, not so they can make more money, but so they can provide better care. So for example, a provider can utilize fixed payment revenue and shared savings to hire a care coordinator, to help ensure their high-risk patients’ providers are communicating with one another about a holistic care plan. Or a social worker may be employed to help connect patients with food, housing, transportation, mental health care, etc., as a means of improving their overall health and well-being. Other practices have incorporated a “lifestyle medicine” nurse practitioner in their staffing model to help patients with diabetes make lifestyle changes to lower their blood sugar levels, or to help those at risk of serious cardiac events improve diet, exercise, and stress management. Creative staffing models funded by value-based care allow for better health outcomes while flattening the cost curve.
In value-based care, providers are able to think less about billing requirements and more about the patient. As Bennett remarks of providers, “I think very few people would tell you that they went into practice medicine so they can learn the proper billing techniques. [The OneCare payment model] really provides an opportunity to provide the kind of care that led them to medicine in the first place.”